One of the deadliest Ebola outbreaks in history continues to worsen in the Democratic Republic of Congo with as many as 319 people now dead.The Ministry of Health said Tuesday that 542 Ebola cases had been recorded in the province of North Kivu -- 494 of which have been confirmed. Of the 319 believed to have died from the virus so far, 271 have been confirmed.On average, Ebola -- which causes fever, severe headache and in some cases hemorrhaging -- kills about half of those infected, but fatality rates in individual outbreaks have varied.

The World Health Organization (WHO) said efforts to contain the outbreak have been hampered due to "non-engagement" from local communities and armed conflict in the region.

North Kivu, which includes the cities of Beni, Kalunguta and Mabalako, remains the epicenter of the outbreak, though cases have been reported in neighboring Ituri province, according to the WHO. The two provinces are among the most populated in the nation and border Uganda, Rwanda and South Sudan.

The public health agency estimates that more than a million refugees and internally displaced people are traveling through and out of North Kivu and Ituri, which could hasten the spread of the virus further.The death of Ebola?

The death of Ebola? 01:32The Congo outbreak is the second-deadliest ever, behind only in West Africa in 2014, when the virus killed more than 11,000 people. It is Congo's 10th epidemic since 1976, and second this year.

WHO and partners continue to respond to the ongoing Ebola virus disease (EVD) outbreak in one of the most complex settings possible. A decline in case incidence has been seen in Beni, the former epicentre. This is a strong positive indication of how effective the response can be despite multiple challenges. However, in Beni and elsewhere, trends must be interpreted cautiously, as delayed detection of cases is expected following recent temporary disruption in response activities due to insecurity. Nevertheless, WHO and partners remain committed, under the government’s leadership and through collaboration across agencies, to addressing challenges and ending the outbreak.

As of 8 January 2019, there have been a total of 628 EVD cases1 (580 confirmed and 48 probable), including 383 deaths (overall case fatality ratio: 61%). Thus far, 222 people have recovered, been discharged from an Ebola Treatment Centre (ETC) and enrolled in a dedicated program for monitoring and supporting survivors.

During the last 21 days (19 December 2018 to 8 January 2019), cases have been reported from ten health zones where the outbreak remains active, including: Katwa (18), Butembo (16), Oicha (13), Beni (13), Kalungata (6), Mabalako (5), Komanda (3), Musienene (2), Kyondo (1) and Nyankunde (1). Overall, cases have occurred in localised hotspots within 16 health zones found in North Kivu and Ituri provinces (Figure 1). Surveillance activities are being maintained to rapidly detect resurgences or reintroduction events in all areas.

Trends in numbers of new cases occurring (Figure 2) reflect the continuation of the outbreak across these geographically dispersed areas, with encouraging declines in case incidence in areas such as Beni. Hard-earned progress could still be lost from prolonged periods of insecurity hampering containment efforts.

Amongst confirmed and probable EVD cases, 61% (385/628) were female and 30% (189/628) were children aged less than 18 years. This includes a high number of cases in infants aged less than 1 year (38) and 1-4 years (58). While investigations to understand the risk factors for this disproportionate burden are ongoing, response teams continue to prioritise these population groups to mitigate, wherever possible, the risk of transmission.

All alerts in affected areas, in other provinces in the Democratic Republic of the Congo, and in neighbouring countries continue to be monitored and investigated. Since the last report was published, alerts were investigated in several provinces of the Democratic Republic of the Congo, Uganda, South Sudan, Rwanda and in a traveller returning from Burundi to Sweden. To date, EVD has been ruled out in all alerts outside the outbreak affected areas. International travellers who may have come into contact with the virus, including a doctor who returned to the United States of America after providing medical assistance in the Democratic Republic of the Congo, are also being followed closely; all remain asymptomatic.

WHO and partners continue to respond to the ongoing Ebola virus disease (EVD) outbreak in one of the most complex settings possible. A decline in case incidence has been seen in Beni, the former epicentre. This is a strong positive indication of how effective the response can be despite multiple challenges. However, in Beni and elsewhere, trends must be interpreted cautiously, as delayed detection of cases is expected following recent temporary disruption in response activities due to insecurity. Nevertheless, WHO and partners remain committed, under the government’s leadership and through collaboration across agencies, to addressing challenges and ending the outbreak.

As of 8 January 2019, there have been a total of 628 EVD cases1 (580 confirmed and 48 probable), including 383 deaths (overall case fatality ratio: 61%). Thus far, 222 people have recovered, been discharged from an Ebola Treatment Centre (ETC) and enrolled in a dedicated program for monitoring and supporting survivors.

During the last 21 days (19 December 2018 to 8 January 2019), cases have been reported from ten health zones where the outbreak remains active, including: Katwa (18), Butembo (16), Oicha (13), Beni (13), Kalungata (6), Mabalako (5), Komanda (3), Musienene (2), Kyondo (1) and Nyankunde (1). Overall, cases have occurred in localised hotspots within 16 health zones found in North Kivu and Ituri provinces (Figure 1). Surveillance activities are being maintained to rapidly detect resurgences or reintroduction events in all areas.

Trends in numbers of new cases occurring (Figure 2) reflect the continuation of the outbreak across these geographically dispersed areas, with encouraging declines in case incidence in areas such as Beni. Hard-earned progress could still be lost from prolonged periods of insecurity hampering containment efforts.

Amongst confirmed and probable EVD cases, 61% (385/628) were female and 30% (189/628) were children aged less than 18 years. This includes a high number of cases in infants aged less than 1 year (38) and 1-4 years (58). While investigations to understand the risk factors for this disproportionate burden are ongoing, response teams continue to prioritise these population groups to mitigate, wherever possible, the risk of transmission.

All alerts in affected areas, in other provinces in the Democratic Republic of the Congo, and in neighbouring countries continue to be monitored and investigated. Since the last report was published, alerts were investigated in several provinces of the Democratic Republic of the Congo, Uganda, South Sudan, Rwanda and in a traveller returning from Burundi to Sweden. To date, EVD has been ruled out in all alerts outside the outbreak affected areas. International travellers who may have come into contact with the virus, including a doctor who returned to the United States of America after providing medical assistance in the Democratic Republic of the Congo, are also being followed closely; all remain asymptomatic.

Public health response

The MoH continues to strengthen response measures, with support from WHO and partners. Priorities include coordination, surveillance, contact tracing, laboratory capacity, infection prevention and control, clinical management of patients, vaccination, risk communication and community engagement, psychosocial support, safe and dignified burials, cross-border surveillance, and preparedness activities in neighbouring provinces and countries.

For detailed information about the public health response actions by WHO and partners, please refer to the latest situation reports published by the WHO Regional Office for Africa:

Ebola situation reports: Democratic Republic of the Congo

WHO risk assessment

WHO reviewed its risk assessment for the outbreak and the risk remains very high at the national and regional levels; the global risk level remains low. This outbreak of EVD is affecting north-eastern provinces of the Democratic Republic of the Congo bordering Uganda, Rwanda and South Sudan. There is a potential risk for transmission of EVD at the national and regional levels due to extensive travel between the affected areas, the rest of the country, and neighbouring countries for economic and personal reasons as well as due to insecurity. The country is concurrently experiencing other epidemics (e.g. cholera, vaccine-derived poliomyelitis, malaria), and a long-term humanitarian crisis. Additionally, the security situation in North Kivu and Ituri at times limits the implementation of response activities.

As the risk of national and regional spread is very high, it is important for neighbouring provinces and countries to enhance surveillance and preparedness activities. The International Health Regulations (IHR 2005) Emergency Committee has advised that failing to intensify these preparedness and surveillance activities would lead to worsening conditions and further spread. WHO will continue to work with neighbouring countries and partners to ensure that health authorities are alerted and are operationally prepared to respond.

WHO advice

International traffic: WHO advises against any restriction of travel to, and trade with, the Democratic Republic of the Congo based on the currently available information. There is currently no licensed vaccine to protect people from the Ebola virus. Therefore, any requirements for certificates of Ebola vaccination are not a reasonable basis for restricting movement across borders or the issuance of visas for passengers leaving the Democratic Republic of the Congo. WHO continues to closely monitor and, if necessary, verify travel and trade measures in relation to this event. Currently, no country has implemented travel measures that significantly interfere with international traffic to and from the Democratic Republic of the Congo. Travellers should seek medical advice before travel and should practice good hygiene.

For more information, see:

WHO Director-General concludes New Year visit to Ebola-affected areas in the Democratic Republic of the Congo Women join hands to oust Ebola from the Democratic Republic of the Congo Summary report for the SAGE meeting of October 2018 Statement on the October 2018 meeting of the IHR Emergency Committee on the Ebola virus disease outbreak in the Democratic Republic of the Congo WHO Interim recommendation Ebola vaccines WHO recommendations for international travellers related to the Ebola Virus Disease outbreak in the Democratic Republic of the Congo Ebola virus disease in the Democratic Republic of the Congo – Operational readiness and preparedness in neighbouring countries Ebola virus disease fact sheet

1Data in recent weeks are subject to delays in case confirmation and reporting, as well as ongoing data cleaning – trends during this period should be interpreted cautiously.

The second-largest, second-deadliest Ebola outbreak in history has reached 600 confirmed cases in five months, health officials said.

Since the outbreak was declared in the Democratic Republic of the Congo on Aug. 1, a total of 649 people have reported symptoms of hemorrhagic fever in the country's northeastern provinces of North Kivu and Ituri. Among those cases, 600 have tested positive for Ebola virus disease, which causes an often-fatal type of hemorrhagic fever, according to Monday night's bulletin from the country's health ministry.

The growing outbreak has a case fatality rate of around 61 percent. There have been 396 deaths thus far, including 347 people who died from confirmed cases of Ebola. The other deaths are from probable cases, the ministry said.

On average, about half of all Ebola patients succumb to the deadly virus, though case fatality rates have varied from 25 to 90 percent in past outbreaks, according to the World Health Organization, the global health arm of the United Nations.

The ongoing outbreak is one of the world's worst, second only to the 2014-2016 outbreak in multiple West African nations that infected 28,652 people and killed 11,325, according to data from the U.S. Centers for Disease Control and Prevention.

This is also the 10th outbreak of Ebola virus disease in the Democratic Republic of the Congo and the most severe that the Central African nation has seen since 1976, when scientists first identified the virus near the eponymous Ebola River.

Ebola virus disease, which has a relatively long incubation period of approximately eight to 21 days, is transmitted through contact with blood or secretions from an infected person, either directly or through contaminated surfaces, needles or medical equipment.

The two provinces where cases in the latest outbreak are being reported share porous borders with South Sudan, Uganda and Rwanda, raising the risk of national and regional spread.

Health workers are facing a number of other challenges to contain the virus, including sporadic attacks from armed groups operating in the mineral-rich, volatile borderlands as well as resistance from the local population in an area that never before had been affected by an Ebola outbreak.

However, this is the first time that a vaccine for prevention and therapeutic treatments are available for use in an Ebola outbreak. The vaccine, which was developed by American pharmaceutical company Merck, has proved effective against the country's previous outbreak in the western province of Equateur.

Nearly 60,000 people have been vaccinated in the outbreak zone since Aug. 8, according to the country's health ministry, which has said that the number of Ebola cases would probably have already surpassed 10,000 if it weren't for the vaccination teams.

Still, the ministry has warned that the epidemic is expected to last for "several" more months and the risk of transmission will remain high.

With health system at breaking point, uncertainty over how virus is being transmitted prompts fears it could range beyond DRCGlobal development is supported byBill and Melinda Gates FoundationAbout this content

Rebecca Ratcliffe

Fri 18 Jan 2019 11.57 GMTLast modified on Fri 18 Jan 2019 18.30 GMT

The number of Ebola cases recorded each day in the Democratic Republic of the Congo is expected to more than double, with concern mounting that uncertainty over how the virus is being transmitted could result in it spreading to neighbouring countries.

On Thursday, the World Health Organization (WHO) reiterated its warning that there is a very high risk of the outbreak spreading not only across DRC but also to Uganda, Rwanda and even South Sudan. The heightened danger of transmission is due to extensive travel between the affected areas.

Efforts to contain the DRC outbreak were hampered after violence related to December’s elections halted prevention work. About 30 health facilities were targeted by protesters in Beni, while efforts to trace anyone who has had contact with the virus were partially suspended due to security concerns.

From October to December, six cases were recorded daily across all affected areas in the east, but numbers are increasing, said Jean-Philippe Marcoux, Mercy Corps’ country director for DRC.

“Now it’s doubling – it’s very possible that it can double again,” said Marcoux. “If we don’t significantly increase the resources, it will keep increasing. It will spread progressively to other health areas and it will be there for a long time.”

Two health centres supported by Mercy Corps are being rebuilt after they were burned to the ground by protesters over the Christmas period. Protesters were angry at a decision to postpone the presidential election in some areas of the country.

Though most of Mercy Corps’ work resumed in January, activities are still hampered by instability, the presence of armed groups and shortages of trained health professionals. Alongside the Ebola crisis, DRC is also experiencing outbreaks of cholera, polio and malaria, according to the WHO, piling more pressure on the country’s overstretched health system.

In some areas, approximately half of recent cases recorded were nosocomial – meaning that transmission occurred in health centres – said Marcoux.

“That is an indication that much more needs to be done at the level of health centres to prevent infection from spreading,” he said.

Marcoux added that greater funding is required for training and monitoring of health workers, and to do preventative community outreach work in areas where it is feared the disease could spread.

There are also concerns that, in some areas, the source of transmission is unclear in up to half of recent cases.Advertisement

As such cases increase, there is a growing risk of unsafe burial practices among communities that have not received specialist support from contact-tracing teams.

Since the outbreak began in August, the WHO has recorded 668 confirmed or probable cases and 410 deaths. Since 1 December, more than a third of cases have occurred in children under 15. Of these, 16 cases were in babies under 12 months.

“If no more is done this will spread to other areas within DRC, and spread to neighbouring countries that are close to affected areas – Uganda, Rwanda, even South Sudan,” said Marcoux.

It is expected the disease will be present for at least another nine to 12 months, he added.

In a situation report, the WHO warned the outbreak was at a critical stage: “The persistence of insecurity threatens to reverse recent progress achieved around disease hotspots such as Beni and Butembo.”

Ebola heads for major city: Outbreak in the Democratic Republic of the Congo which has killed 419 people is moving towards a trading hub home to one million inhabitants

If the virus spreads to Goma 'all bets are off' in attempts to control the virus Cases are appearing in towns further south from the centre of the outbreak At least 685 people have been infected in the epidemic which began in August

By Sam Blanchard Health Reporter For Mailonline

Published: 09:13, 21 January 2019 | Updated: 15:26, 21 January 2019

The deadly Ebola outbreak in the Democratic Republic of the Congo is spreading towards a city home to one million people.

Cases have begun appearing in a district between the two major cities involved in the epidemic, suggesting the virus is spreading south.

If Ebola does make it to the major city of Goma then 'all bets are off' for the bid to control the outbreak, one health official said.

A total of 419 people have died in the killer outbreak already, with the DRC's health ministry reporting 685 cases.

Experts fear Ebola is spreading south from the smaller cities of Beni and Butembo, where most of the outbreak has taken place so far, to Goma, which has a population of one million people and is close to the border with Rwanda

Experts fear Ebola is spreading south from the smaller cities of Beni and Butembo, where most of the outbreak has taken place so far, to Goma, which has a population of one million people and is close to the border with Rwanda

A total of 419 people have now died of Ebola, the Democratic Republic of Congo's health ministry tweeted yesterday. There have been 685 cases of the illness which began in August

The health ministry reported on Friday that there had been four Ebola cases confirmed in the town of Kayina.

The area is halfway between the cities of Butembo, where people are already dying of Ebola, and Goma, where experts fear it could wreak havoc.

Goma has almost double the population of Butembo, meaning there is a much higher potential for the virus to spread quickly.

And Goma sits on the border with Rwanda, adding an extra threat of Ebola spreading out of the country.

'These are crossroad cities and market towns,' Dr Peter Salama, head of the World Health Organization's Health Emergencies Program told Vox.

He said the contagious illness spreading in areas where people are constantly travelling in and out 'raises the alarm'.

The WHO and DRC's health ministry have already sent rapid response and vaccination teams to Kayina, and they've set up a lab in Goma as a precaution.

More than 60,000 people have been given an experimental vaccine to protect against the Ebola virus (pictured, a woman being vaccinated in Mangina, North Kivu)

More than 60,000 people have been given an experimental vaccine to protect against the Ebola virus (pictured, a woman being vaccinated in Mangina, North Kivu)

Vaccination has helped to slow the spread of the virus, experts say, but ongoing violent conflict, political protests and distrust of medical workers makes it particularly difficult to control.

Aggressive protests since a controversial election in December – which the losing party claims was rigged – continue to endanger patients and health workers.

Experts predict the country has months more suffering in store before the outbreak comes to an end.

But this could be longer if the illness breaks out of the North Kivu region, in the country's north-east, where it has so far been contained.Violent political protests surrounding a controversial election in December – which the losing party has claimed was rigged – have put health workers and Ebola patients in danger of attack (Pictured: A crowd of protestors wait to cast their votes in Kinshasa, the capital city)

Violent political protests surrounding a controversial election in December – which the losing party has claimed was rigged – have put health workers and Ebola patients in danger of attack (Pictured: A crowd of protestors wait to cast their votes in Kinshasa, the capital city)Families cannot be near or touch their relatives who have died of Ebola because the virus, which is spread through bodily fluids, can still be passed on after death

Families cannot be near or touch their relatives who have died of Ebola because the virus, which is spread through bodily fluids, can still be passed on after death

Writing in Foreign Policy last week, Ebola expert Laurie Garret said: 'Were Ebola to reach [Goma], a top WHO official told me, “all bets are off,” for stopping the epidemic.'

And she added: 'If Ebola hitchhikes its way in an unwitting human carrier across Lake Edward into Uganda, down the highway to Goma and Rwanda, or up the Semliki River toward South Sudan, the world community will face tough choices.

'Option one: Keep on muddling through with the tools, personnel, and funding that have carried the response to date.

'Option two: Declare a global public health emergency, escalating financing and on-the-ground response to the multibillion-dollar scale seen in West Africa.

'Option three: Dedicate massive financial resources to pushing Merck and other vaccine-makers to rapidly manufacture millions of doses, and deploy literal armies, acting as security alongside an enormous public health deployment to immunize tens of millions of people in the region.' WHAT IS EBOLA AND HOW DEADLY IS IT?

Ebola, a haemorrhagic fever, killed at least 11,000 across the world after it decimated West Africa and spread rapidly over the space of two years.

That epidemic was officially declared over back in January 2016, when Liberia was announced to be Ebola-free by the WHO.

The country, rocked by back-to-back civil wars that ended in 2003, was hit the hardest by the fever, with 40 per cent of the deaths having occurred there.

Sierra Leone reported the highest number of Ebola cases, with nearly of all those infected having been residents of the nation.

WHERE DID IT BEGIN?

An analysis, published in the New England Journal of Medicine, found the outbreak began in Guinea - which neighbours Liberia and Sierra Leone.

A team of international researchers were able to trace the epidemic back to a two-year-old boy in Meliandou - about 400 miles (650km) from the capital, Conakry.

Emile Ouamouno, known more commonly as Patient Zero, may have contracted the deadly virus by playing with bats in a hollow tree, a study suggested.

Three more people in the Democratic Republic of the Congo (DRC) were confirmed as having Ebola in the country's ongoing outbreak, and in a related development, researchers from Liberia and the United States today reported genetic evidence of the Ebola outbreak virus in a bat in Liberia, the first such detection in West Africa.

Also, the DRC media reported another security incident in the outbreak region, and researchers published new findings on clinical patterns and health worker vaccination from studies conducted in Sierra Leone during its outbreak in 2014-16.Cases continue in Katwa hot spot

The DRC's health ministry today said two of the latest patients are from Katwa, one of the latest outbreak hot spots located just southeast of Butembo, and Biena health zone, which is west of Butembo.

The illnesses bring the overall outbreak total to 715, but the ministry noted that it has removed a duplicate case from Mabalako from its count. The number includes 666 confirmed and 49 probable cases.

Health officials are still investigating 236 suspected cases, and teams have now immunized 65,963 people with the Merck's unlicensed VSV-EBOV vaccine.

Also, the ministry said 4 more people died from their infections, including a patient from Biena who died in the community setting and 3 who died in Ebola treatment centers—2 in Butembo and 1 in Katwa. So far 443 deaths have been reported in the DRC outbreak.

In Beni, which was the main Ebola hot spot but has recently shown a steep drop in cases, a group of people vandalized a local hospital the night of Jan 21, apparently targeting Ebola responders that they thought were inside, according to a translation of a local media report.

The attackers threatened to burn the facility and destroyed the door and windows before they were scared off, the report said. A nurse quoted in the story said the facility had hosted Ebola vaccinators, that they felt safe there, and that she welcomed their help in fighting the epidemic.Bat findings provide more reservoir clues

Liberia's government and its partners, which include Center for Infection and Immunity (CII) at the Columbia University Mailman School of Public Health and EcoHealth Alliance, announced the bat findings today in a press release.

As part of bat sampling with the US Agency for International Development (USAID) PREDICT project, scientists found Ebola genetic material and Ebola antibodies in a greater long-fingered bat from Nimba district in northeastern Liberia, according to a press release from Columbia University's Mailman School of Public Health. The project also included researchers from Columbia's Center for Infection and Immunity and EcoHealth Alliance.

The bat species that yielded Ebola evidence is found in West Africa and other regions and is important to agriculture, because they eat insects that damage crops. Unlike other bats, the long-fingered type doesn't roost in homes or building and instead are found in forests, caves, and mines. According to the report, Liberia's government is using that information to teach the public about how to avoid exposure and increase their awareness of the animals' positive impact on the environment.

Evidence from 20% of the bat's genome suggests that it is closely related to the Zaire Ebola virus species, which was involved in West Africa's massive 2014-16 outbreak and is also implicated in the current DRC outbreak. Researchers at CII are trying to determine if the strain from the bat is a genetic match with the one that caused West Africa's outbreak.

The researchers said the finding brings scientists closer to understanding the source of Ebola in humans.

Simon Anthony, DPhil, assistant professor of epidemiology at CII, said in the release that there has been speculation that Ebola in humans came from bats, but no direct evidence has yet been found. "It is possible that there are also other bat species that carry Ebola. Going forward, we will be analyzing additional specimens to fill in the picture," he said.

According to a news report on the discovery in Science today, two other Ebola species were found in a related insect-eating bat, but other indications have pointed to fruit bats as a possible reservoir. Jon Epstein, DVM, with EcoHealth Alliance and who leads the USAID-PREDICT project in Liberia, told Science that the new finding hints at the possibility that Ebola has multiple hosts that may vary by region.

Another researcher not involved in the work, Fabian Leendertz, DVM, with the Robert Koch Institute in Berlin, told Science that a next step would be to sample the insects that the bats eat to see if they harbor the virus.

In other Ebola research developments, scientists reported new findings related to clinical disease in kids and vaccination in health workers, both based on experiences in Sierra Leone's outbreak:

A review of clinical disease and treatment outcomes in 139 patients younger than 15 years found that 56.1% were girls and 51.1% were students and that certain factors at the time of admission were associated with greater odds of dying from the disease, according to the report today in BMC Infectious Diseases. The factors included male gender, abdominal pain, vomiting, conjunctivitis, and difficulty breathing.

A 2018 survey on staff turnover and Ebola vaccine acceptance in 305 health workers in Sierra Leone found that 76% of them had a positive opinion of Ebola vaccination and that vaccination against Ebola is feasible if employment is stable, but repeated vaccination at the start of employment may be needed to maintain high vaccination coverage. Researchers reported their findings yesterday in Vaccine.

The number of people killed in an Ebola outbreak in eastern DR Congo has risen to 443, health authorities have announced, as new President Felix Tshisekedi began his first full day in office on Friday.

The rising death toll -- up by more than 40 in the past ten days -- emphasises the challenge of controlling the epidemic in the strife-torn east and is just one of a host of complex issues facing Tshisekedi.

Tshisekedi was sworn in on Thursday following a long-delayed and bitterly disputed election, replacing Joseph Kabila after 18 turbulent years in charge of sub-Saharan Africa's biggest country.

In his inaugural address, Tshisekedi promised a new era of respect for human rights. He also faces entrenched poverty, corruption and fighting between militias who control parts of the east.

In a bulletin on Thursday, the health ministry outlined the growth of the Ebola outbreak.

"Since the start of the epidemic, the total number of cases is 715, including 666 confirmed and 49 probable. In all, there have been 443 deaths" in the provinces of North Kivu and Ituri, the ministry said.

DR Congo, formerly Zaire, has seen 10 outbreaks of the highly contagious haemorrhagic disease since it was first identified in 1976 near the Ebola river in the northwest of the country.

The latest outbreak was declared on August 1 in the region of Beni, a major market town in North Kivu, and quickly spread to neighbouring Ituri province.

The ministry said 248 people have recovered from the Ebola virus, while "236 suspect cases" were under investigation -- down one from the previous bulletin on January 15.

The Beni region and parts of Ituri regularly come under attack from local armed groups and foreign rebels, particularly the feared Allied Democratic Forces (ADF) from neighbouring Uganda.

The presidential election, held on December 30, was cancelled in Beni, officially because of the Ebola outbreak and regional insecurity.

CINCINNATI--A Phase 1 clinical trial of investigational vaccines intended to protect against Zaire ebolavirus (Ebola) is underway at Cincinnati Children's Hospital Medical Center in the United States. The study is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH).

Cincinnati Children's is one of nine NIH/NIAID-funded Vaccine and Treatment Evaluation Units (VTEUs). Part of an international effort to stop Ebola from spreading, the trial will test two experimental vaccines together for their safety and ability to produce an immune response in healthy volunteer participants.

"Researchers are looking for new ways to stop these outbreaks and to treat people who become infected and develop Ebola virus disease. The development of preventive vaccines for Ebola is a top global public health priority," said Paul Spearman, MD, of Cincinnati Children's and lead investigator of the trial. He is director of the ivision of Infectious Diseases.

Ebola is a serious and sometimes fatal disease caused by infection with one of the Ebola viruses. Ebola virus disease has a wide-ranging fatality rate of about 30-90 percent, depending on virus species. The hemorrhagic fever can affect organs, damage blood vessels and the body's ability to regulate itself. Once a person is infected with an Ebola virus, it can then be spread from person to person through close contact with infected body fluids.

Ebola viruses have generally caused infections in a small number of people in Central Africa each year, although there have been several Ebola outbreaks since 2013. The Ebola epidemic in West Africa that began in 2013 made more than 28,000 people sick, causing more than 11,000 deaths and spread into other countries around the world. A current outbreak in the Democratic Republic of Congo has so far caused more than 700 confirmed and probable cases of Ebola virus disease.

Blueprint for Immunity

Researchers on the current study will examine how the vaccines work in the body to stimulate responses in the immune system that may protect against Ebola viruses. Laboratory evaluations of the vaccines are led by Karnail Singh, PhD, in the Division of Infectious Diseases at Cincinnati Children's. Singh's laboratory focuses on the development, characterization and evaluation of candidate vaccines for Ebola virus disease.

The trial is studying two experimental Ebola vaccines; the ChAd3-EBO-Z vaccine and the MVA-BN®-Filo vaccine. These are weakened live-vector vaccines that cannot effectively grow in human cells but generate strong immune responses to Ebola virus proteins.

Spearman said previous laboratory research shows combining the two vaccines is a promising approach to generate potentially protective anti-Ebola responses. A major goal of the current trial is to use systems biology tools that provide a biological blueprint of the responses. This will provide a better understanding of why adding a MVA- BN®-Filo booster after priming the body with ChAd3-EBO-Z enhances the character and magnitude of immune response.

This study will enroll up to 60 healthy volunteers between 18 to 45 years of age. Volunteers will be randomly assigned to one of three groups. All participants will receive one dose of the ChAd3-EBO-Z vaccine followed by a second dose eight days later of either: 1) the ChAd3-EBO-Z (20 participants); 2) the MVA-BN®-Filo vaccine (20 participants), or 3) a placebo (20 participants).

Participants will be monitored closely for adverse events for six months after initial vaccination during at least 12 clinic visits. During these visits, volunteers will receive blood tests to evaluate potential immune responses to both of the experimental vaccines. Each volunteer will participate in the trial for approximately seven months.

###

For information about enrolling to volunteer for the study, click here or call 513-636-7699.For more background information about the study, visit this link at ClinicalTrials.gov or use the identifier NCT03583606. Funding support from NIAID comes via HHSN272201300016.

Legacy of Vaccine Development

Cincinnati Children's is an active participant in global vaccine research and has a long legacy of vaccine development. This includes the oral polio vaccine and a vaccine for rotavirus. As an NIH-sponsored Vaccine and Treatment Evaluation Unit, Cincinnati Children's is helping study vaccines for seasonal influenza, H7N9 bird flu, Shigella, respiratory syncytial virus (RSV), and others.

Yambio, 28 January 2019 – The Ministry of Health of South Sudan, with support from the World Health Organization (WHO), Gavi, the Vaccine Alliance, UNICEF and the US Centers for Disease Control and Prevention (CDC) and other partners, today started vaccinating health workers and other front-line responders against Ebola as part of preparedness measures to fight the spread of the disease.

Vaccination began in Yambio, Gbudue State, but health workers in Tombura, Yei and Nimule as well as the capital city, Juba, will also be offered the vaccine. These are high-risk areas bordering the Democratic Republic of the Congo (DRC), now experiencing its tenth outbreak of Ebola. The outbreak began 1 August 2018. Neighbouring countries have not reported any cases of Ebola, but preparedness is crucial.

As part of these preparedness activities, South Sudan received 2 160 doses of the Ebola vaccine (rVSV-ZEBOV) from Merck, the vaccine developer. The vaccine offers protection against the Zaire strain of the virus, which is the one affecting DRC at present.

“It is absolutely vital that we are prepared for any potential case of Ebola spreading beyond the Democratic Republic of the Congo,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “WHO is investing a huge amount of resources into preventing Ebola from spreading outside DRC and helping governments ramp up their readiness to respond should any country have a positive case of Ebola.”

Vaccination is one of a raft of preparedness measures South Sudan is putting into place. WHO has deployed more than 30 staff members to support these activities.

In particular, WHO has helped train 60 health workers in good clinical practice principles and protocol procedures to administer the yet-to-be-licensed Ebola vaccine. To detect any travellers entering the country who may be infected with the virus, the Ministry of Health, with the support of its partners, has established 17 screening points. Nearly 1 million people have been screened to date.

WHO is also supporting engagement with communities, active surveillance for the disease at the community and health facility levels, strengthening capacity for infection prevention and control and case management, and supporting dissemination of Ebola information through the media. Local laboratory capacity to test samples taken from people suspected of having Ebola is also being strengthened. Protective gear for responders has been stockpiled in a dedicated warehouse.

Gavi, the Vaccine Alliance, in addition to its work making the Ebola vaccine stockpile available, is providing US$2 million to support the WHO’s vaccination efforts in countries neighbouring the DRC, including South Sudan.

“Although research is ongoing, the evidence so far suggests the Ebola vaccine is a highly effective tool to help stop epidemics and can be used to prevent this national outbreak from becoming a regional one,” said Dr Seth Berkley, CEO of Gavi. “Vaccinating front-line workers and health workers in South Sudan border regions will be crucial: an outbreak in South Sudan would be deeply concerning.”

Uganda began vaccinating its front-line workers in November 2018. So far, more than 2 600 health workers in eight high-risk districts have been immunized. In DRC, more than 66 000 people have been vaccinated – more than 21,000 of them are health and other front-line workers. Rwanda also plans to vaccinate its front-line responders.

The yet-to-be-licensed rVSV-ZEBOV vaccine has been shown to be highly protective against the Zaire strain of the Ebola virus in a major trial. Though not yet commercially licensed, the vaccine is being provided under what is known as “compassionate use” in the ongoing Ebola outbreak in North Kivu province of DRC as part of recommendations from the Strategic Advisory Group of Experts on Immunization. This vaccine was also used in the Ebola outbreak in Equateur province of DRC in May–July 2018.

Over the weekend and through today, the Democratic Republic of the Congo (DRC) reported 15 more Ebola cases, including 5 earlier probable infections from Komanda, one of the areas where responders had faced security challenges.

Also, the country's health ministry shed more light today on factors that have fueled a steep rise in cases in Katwa, which has become the current hot spot, and South Sudan today launched a campaign to immunize health workers and frontline responders with VSV-EBOV vaccine.Case count climbs to 736

In the latest three daily updates, the latest cases were from a several locations. Of the 10 confirmed cases, 4 are in Beni, an area where cases have declined but was once the outbreak's epicenter. Two others are in Oicha, and four are in Katwa, the current hot spot.

The five probable cases in Komanda were added after investigations into deaths that occurred in November and December concluded that they were likely due to Ebola.

The new cases boost the overall outbreak total to 736 cases, which include 682 confirmed and 54 probable infections. In its update today, the ministry said health officials are still investigating 161 suspected Ebola cases.

Besides the 5 deaths in the earlier probable cases, the health ministry reported 8 more deaths, including 7 patients from Ebola treatment centers in Katwa, Butembo, and Mabalako. One of the deaths involved a patient from Oicha who died in the community.

In its update today, the DRC's health ministry said several factors have led to a significant increase in cases in Katwa this month, including local groups that have obstructed response activities such as immunization, household decontamination, and safe and dignified burials.

And despite broad community sensitization efforts, many Katwa residents continue to deny that Ebola exists, the ministry said. It added, "However, significant progress in community involvement in Katwa has been achieved, in particular through greater involvement of women's associations."

Also, demonstrations related to problems with the DRC's national election in late December brought the outbreak response to a standstill for several days, the ministry said, which resulted in a large drop in Ebola alerts that officials received and investigated. As a result, people with Ebola weren't quickly taken to Ebola treatment centers for care, and contacts weren't vaccinated.

Several "dead" days since the beginning of the year in Butembo and Katwa have also slowed the Ebola response. "When the response is slow, the risk of geographical expansion of the epidemic increases due to uncontrolled displacement of patients and their contacts," it said.

After the response interruptions, people who were contacts of confirmed cases moved and brought the virus to two new health zones in January: Mangurujipa and Kayina. And investigators found that Kayina's confirmed case-patients are members of a Katwa family who participated in the unsafe burial of a relative. Infections have been confirmed in 21 family members.Officials push back against assertions

In an unusual step, the health ministry in its Jan 26 update disputed some information in a Jan 15 Foreign Policy article that discussed the challenges in the DRC's outbreak.

It said the article contained some "dubious and problematic" assertions, for example, that the health workers were threatened by soldiers, gangs, arms smugglers, and rapists. The health ministry clarified that most assaults and threats on responders have come from people the residents of Ebola-affected communities. It added that several Ebola cases have been detected in areas controlled by armed groups that have agreed to work with response teams to curb the outbreak.

The health ministry also said the article inappropriately linked possible sexual transmission in survivors and the use of rape as a weapon of war. It said no cases of "military rape or rape contamination" have been reported in outbreak areas and that there is no objective evidence to back up the assumption that "rapist and robber soldiers" could spread the virus.

The ministry said Ebola survivors and their families are being followed by clinical psychologists and that so far rape has not been mentioned as a source of trauma in populations affected by the outbreak.South Sudan vaccine launch

In South Sudan, which has a border not far from the DRC's outbreak area, the health ministry and its partners today began vaccinating health workers and frontline responders against Ebola as part of larger preparedness efforts, according to a statement today from the World Health Organization (WHO) South Sudan office. Groups supporting the efforts include the WHO; Gavi, the Vaccine Alliance; UNICEF; and the US Centers for Disease Control and Prevention.

Vaccination began in Yambio in Gbudue state, and health workers in the cities of Tombura, Yei, Nimule, and South Sudan's capital city of Juba—all considered high-risk areas—will also be offered the vaccine.

The country has received 2,160 doses of VSV-EBOV from Merck.

Matshidiso Moeti, MD, the WHO's regional director for Africa, said in the statement, "It is absolutely vital that we are prepared for any potential case of Ebola spreading beyond the Democratic Republic of the Congo." The WHO said it has deployed more than 30 staff members to support preparedness efforts in South Sudan, has helped train 60 health workers, and established 17 screening points that have screened nearly 1 million people so far.

Gavi has assisted with the Ebola vaccine stockpile and has provided $2 million to support WHO vaccination efforts in countries that neighbor the DRC's Ebola-affected area.

In November, health officials launched a similar vaccination campaign in Uganda, one of the other neighboring countries.

With children accounting for 30% of the confirmed and probable Ebola cases, UNICEF scales up its response to halt spread of the disease

30 January 2019 – Since the latest Ebola outbreak in the Democratic Republic of the Congo (DRC) was declared six months ago on 1st August 2018, more than 740 people – 30 per cent of whom are children – have been infected with the disease, including over 460 who have died, and 258 that have survived Ebola. Alongside the Government and partners, UNICEF is scaling up its response to assist victims, control the spread of the disease and ultimately end the deadly outbreak.

This is the 10th Ebola outbreak in the DRC and the country’s worst. It is also the world’s second largest Ebola outbreak in history after the one in West Africa in 2014-2016. The response to this latest outbreak continues to be hampered by insecurity, frequent movement of people in the affected areas, and resistance from some communities.

“While we have been able to largely control the disease in Mangina, Beni and Komanda, the virus continues to spread in the Butembo area, largely because of insecurity and population movement,” said Dr. Gianfranco Rotigliano, UNICEF Representative in the DRC. “We are scaling up our response and deploying additional staff in the health zones of Butembo and Katwa, where 65 per cent of the new Ebola cases in the last three weeks have occurred.”

Since the beginning of the epidemic, UNICEF and its partners have deployed more than 650 staff to work with Government, civil society, churches, and non-governmental organizations – to assist people and families who’ve been infected and to raise awareness about the best hygiene and behavioral practices to prevent Ebola from spreading.

UNICEF’s Ebola response focuses on community engagement, providing water and sanitation, making schools safe from Ebola and supporting children and families infected and affected by Ebola. UNICEF aims to control and prevent the spread of the disease, and ultimately stop the outbreak; to reduce Ebola-related deaths among those infected; and to provide protection, alleviate suffering and give assistance to affected children and families.

People who’ve been infected, as well as affected families and their children, including children orphaned by Ebola and unaccompanied children, continue to receive psychosocial support to help them cope with the consequences of the Ebola disease. UNICEF is also providing a protective environment for children in schools and nutrition assistance, including to children and adults in Ebola Treatment Centers.

“Our teams in Mangina, Beni, Oicha, Komanda, Butembo and Lubero are working tirelessly with this multi-pronged approach to end the Ebola outbreak as quickly as possible, and to help affected children and families,” stressed Dr. Rotigliano.

The number of people infected in the Democratic Republic of the Congo (DRC) Ebola outbreak grew by nine today, as health officials in the neighboring Haut Uele province took steps to prevent the spread of a disease from a resident who was exposed to the virus in Katwa.Spike in Katwa cases continues

Of the nine newly confirmed cases announced today by the DRC health ministry, eight are in Katwa, the current hot spot where authorities face complex challenges, including insecurity, community resistance, and the after effects of a response slowdown in late December caused by election-related protests.

The other case is in Beni. Investigations are under way into 187 suspected Ebola cases. Today's developments push the outbreak total to 752 cases, including 698 confirmed and 54 probable cases.

The health ministry also said 4 more people died from their Ebola infections, 3 of them in community settings in Katwa and 1 in the Butembo Ebola treatment center. The new fatalities lift the outbreak's death count to 465.

Infected traveler in Haut Uele province

A health team has been sent to a city of Watsa in neighboring Haut Uele province after a young trader was hospitalized there after his likely exposure in Katwa, the health ministry said in its update today, noting that Oly Ilunga Kalenga, MD, the country's health minister, arrived there yesterday to oversee operations.

Haut Uele province is north of Ituri province and borders South Sudan. So far, Ebola cases in the current outbreak have been confirmed in only two DRC provinces: North Kivu and Ituri.

The man lives in Watsa but travels back and forth between Butembo and his hometown. An investigation into his illness suggests he was exposed to Ebola during a stay in Katwa, which is on the eastern outskirts of Butembo. Watsa is about 300 miles north of Butembo.

Healthcare teams were sent to vaccinate relatives and frontline health workers and to decontaminate the patient's home and the health center where he was treated.

Soldiers among recent deaths in Beni

In a separate development, two soldiers with the DRC's army have died from Ebola in Beni, Agence-France Presse (AFP) reported today, quoting an army spokesman.

The army source told AFP that three other soldiers are under observation and that steps have been taken to prevent illness in DRC troops.

The Ministry of Health (MoH), WHO and partners continue to respond to an outbreak of Ebola virus disease (EVD), despite persistent challenges around security and community mistrust impacting response measures. Relatively high numbers of cases were reported in recent weeks (Figure 1), mostly driven by the outbreak in Katwa Health Zone; the current focus of large scale response activities. Smaller clusters continue to be reported beyond Katwa Health Zone, including from Beni and Oicha; however, teams have quickly and systematically responded to these clusters to prevent onward transmission and guard against further geographical expansion of the outbreak. Teams are also working actively to strengthen community trust and participation in all affected areas.

As we approach six months since declaration of the outbreak, there have been a total of 752 EVD cases1 (698 confirmed and 54 probable) reported, including 465 deaths (overall case fatality ratio: 62%) as of 29 January 2019. Thus far, 259 people have been discharged from Ebola Treatment Centres (ETCs) and enrolled in a dedicated program for monitoring and supporting survivors. Among cases with a reported age and sex, 59% (439/750) were female, and 30% (224/749) were aged less than 18 years; including 115 children under 5 years.

The outbreak in Katwa and Butembo health zones is partly being driven by nosocomial transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission. In Katwa during the past 3 weeks (since 9 January), 49 health structures were identified where confirmed cases were hospitalised, including nine health centres where nosocomial transmission potentially occurred. Moreover, during the same period, eight new health care worker (HCW) infections were reported in Katwa; overall, 65 HCWs have been infected to date. Response teams are following up with the identified health care facilities to address gaps around triage, case detection and infection prevention and control measures.

Public health response

The MoH continues to strengthen response measures, with support from WHO and partners. For detailed information about the public health response actions by WHO and partners, please refer to the latest situation reports published by the WHO Regional Office for Africa:

WHO risk assessment

WHO reviewed its risk assessment for the outbreak and the risk remains very high at the national and regional levels; the global risk level remains low. This Ebola virus outbreak is affecting north-eastern provinces of the Democratic Republic of the Congo bordering Uganda, Rwanda and South Sudan. There is a potential risk for transmission of Ebola virus at the national and regional levels due to extensive travel between the affected areas, the rest of the country, and neighbouring countries for economic and personal reasons as well as due to insecurity. The country is concurrently experiencing other epidemics (e.g. cholera, vaccine-derived poliomyelitis, malaria), and a long-term humanitarian crisis. Additionally, the security situation in North Kivu and Ituri at times limits the implementation of response activities.

As the risk of national and regional spread is very high, it is important for neighbouring provinces and countries to enhance surveillance and preparedness activities. The International Health Regulations (IHR 2005) Emergency Committee has advised that failing to intensify these preparedness and surveillance activities would lead to worsening conditions and further spread. WHO will continue to work with neighbouring countries and partners to ensure that health authorities are alerted and are operationally prepared to respond.

WHO advice

International traffic: WHO advises against any restriction of travel to, and trade with, the Democratic Republic of the Congo based on the currently available information. There is currently no licensed vaccine to protect people from the Ebola virus. Therefore, any requirements for certificates of Ebola vaccination are not a reasonable basis for restricting movement across borders or the issuance of visas for passengers leaving the Democratic Republic of the Congo. WHO continues to closely monitor and, if necessary, verify travel and trade measures in relation to this event. Currently, no country has implemented travel measures that significantly interfere with international traffic to and from the Democratic Republic of the Congo. Travellers should seek medical advice before travel and should practice good hygiene.

Today marks 6 months since the 10th outbreak of Ebola was declared in the Democratic Republic of the Congo. Before I say anything else, I want to recognize and thank our WHO and partner colleagues in the field for their courage, commitment and professionalism. They make us all proud. I also want to acknowledge the steadfast leadership of the Democratic Republic of Congo Ministry of Health and other colleagues. No country would wish to face this deadly pathogen, and their spirit of cooperation is what allows us all to face the virus together.

As we look back on these 6 months, we can clearly see the strategies that have been successful at controlling the outbreak in some of the affected areas such as Mangina, Béni, Komanda and Oicha, though we continue to face flare-ups in some of these areas and outbreaks in others.

What has worked is public health measures such as training health workers on infection prevention and control in health centres; closer engagement with communities--particularly women’s and religious groups; other public health measures such as case investigation, and contact tracing, alongside the use of newer tools. So far 70,000 people have agreed and received the investigational vaccine, and 350 patients have been treated with therapeutic drugs, available for the first time at this scale.

In each town or area, the outbreak has slightly different drivers. The outbreaks in Butembo and Katwa health zones are partly being driven by transmission in private and public health centres, with about a fifth of patients reporting contact with a health care facility before their onset of illness. The rest are being infected within communities.

We therefore tailor our actions accordingly both in the health facilities and at community level.

Let me provide some examples:

In order to strengthen infection prevention and control practices, we prioritize facilities according to risk, we train health workers and monitor their progress, and provide incentives to encourage best practices. We’re also working with the highest risk health facilities in as yet non-affected health zones in North Kivu and surrounding provinces, and countries. In addition, we work with health facilities to ensure they and the communities report all deaths, allowing teams to conduct safe and dignified burials. WHO, the Red Cross, UNICEF, and other partners work together to collect and analyze community feedback, to ensure our actions are tailored appropriately and address community concerns and needs. Underpinning this all, the UN peacekeeping force provides us the security umbrella under which we can function.

These are the approaches that work. But let us step back to consider the context. The Ebola outbreak is happening in a country that is also responding to outbreaks of polio, cholera, measles, and monkeypox and the health needs related to the ongoing humanitarian crisis in other provinces. This is putting a lot of pressure on the health system in general.

In Béni, one of the Ebola affected areas, we had to respond to a malaria outbreak at the same time as the Ebola response. This required additional teams working hand-and-hand with our Ebola response teams. The malaria Mass Drug Administration campaign reaching 300,000 people in Béni, and helped to alleviate pressure on the health system.

Ultimately, this outbreak has put into even sharper focus the weaknesses in the health system, and reinforced, once again, our ultimate message: stronger health systems are the only way to rapidly detect, respond and eventually end outbreaks.

By using proven public health measures and newer tools at hand, under the government’s leadership and working collaboratively across agencies, WHO is committed to addressing these challenges and ending the outbreak.

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